Use of absorbable tacker for Nyhus IIIa left inguinal hernia

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摘要

We present the case of an inguinal hernia in a male patient, treated laparoscopically through a TAPP approach. The use of innovative absorbable tackers and its advantages are shown and thoroughly explained.

分類

routine cases

關鍵字

Absorbable tacker, Nyhus IIIa left inguinal hernia

媒體類型

期間

05'00''

刊物

2008-12

普通的

最愛

音訊

副標題

數位出版

WeBSurg.com, Dec 2008;8(12).
URL: http://www.websurg.com/doi-vd01en2473.htm

Use of absorbable tacker for Nyhus IIIa left inguinal hernia

1. Clinical case presentation 00'10''

This is the case of a patient presenting with a Nyhus type IIIa hernia treated laparoscopically. A trans-abdominal preperitoneal approach is used with an open laparoscopic approach of the abdomen. Three ports are used, one 10mm for the camera, and two 5mm ports in order to introduce graspers and scissors.

2. TAPP approach and landmark identification 00'36''

Monopolar cautery is used with the scissors. The incision of the peritoneum is made from the anterior and superior iliac spine horizontally and going to the midline. The peritoneum is progressively freed from its attachments in order to identify all the landmarks. After the complete incision, the pubic spine is immediately identified by lowering the bladder using a two-hand manipulation, graspers and scissors. This identification represents the internal dissection of the hernia. The direct sac is dissected afterwards. Coagulation is carefully done in order to avoid postoperative hematoma. The sac of the direct hernia is very clearly and rapidly identified as is seen here. It is progressively dissected and re-introduced in the direct hernia. Coagulation is done very carefully here again to avoid any postoperative hematoma.

3. Dissection of cord elements 02'10''

The elements are progressively dissected from the peritoneum, here the spermatic vessels and later the cord. Dissection is carefully done in order to avoid any injury of the peritoneum, which will be used to cover the mesh afterwards. Monopolar cautery is applied at a distance of 5mm from the peritoneum in order to avoid any injury. The elements of the cord, spermatic vessel and ductus deferens are clearly identified, preserved, and the triangle of Doom is not dissected in order to avoid any vascular injury. In this patient, the vas deferens is clearly identified and preserved from any cautery.

4. Hernia sac fixation 02'58''

After this complete dissection, the sac is inverted and fixed to the inguinal ligament with absorbable Protacks. This inversion aims at preserving from postoperative seromas, which are very frequent after the laparoscopic management of direct hernias. In order to apply this new tacker safely, some pressure must be applied on the system. The advantage of the absorbable character of this tacker is that it aims at avoiding postoperative pain after it comes back to normal.

5. Mesh placement and fixation 03'40''

A polyester mesh is applied in this case. We always use very large meshes, with a size of 15 by 12cm in order to largely cover the defect. After a good application of the abdominal wall, the mesh is just fixed with two or three staples. Here again, we use absorbable tackers in order to avoid postoperative pain.

6. Mesh covering 04'10''

After its fixation, the mesh is completely covered by the peritoneum. This is fixed with the absorbable tackers, which aim at avoiding postoperative adhesions. The mesh is completely covered to avoid any contact with the ball. The size of the hernia needs a large amount of peritoneum to cover completely the mesh. Classically, we also like to invert the sac in order to avoid postoperative herniation into this sac and to cover the mesh largely. Exsufflation is completed under direct visual control.

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